Improvement Plan - Canterbury District Health Board · Canterbury’s 2018/19 Improvement Plan and...
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1 System Level Measures Improvement Plan CANTERBURY HEALTH SYSTEM 2019-20
Transcript of Improvement Plan - Canterbury District Health Board · Canterbury’s 2018/19 Improvement Plan and...
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System Level Measures
Improvement Plan
C A N T E R B U R Y H E A L T H S Y S T E M
2019-20
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INTRODUCTION
The Canterbury Health System places a high priority on implementing the System Level Measures Framework to
support change and system improvement. The connections and trust developed through our alliancing approach
not only contributes to delivering on Actions to Improve Performace within the System Level Measures but
contributes to our health system having the ability to work effectively together in unprecedented times of need.
This was demonstrated on March 15, 2019 when our community was exposed to another extreme and traumatic
event, when two Christchurch mosques were the target of a terrorist attack. Our response was exemplary with a
community response supporting the acute hospital trauma response, 12 acute operating theatres ran non-stop for
24 hours, and staff worked overtime to treat and support the victims and their families. General practice and
primary mental health teams collaborated to provide free and streamlined support, and Mana Ake provided a
platform to reach into school communities to distribute information and to provide immediate guidance, determine
need, and respond accordingly.
We are pleased to report we have comprehensively progressed the Actions to Improve Performance detailed in
Canterbury’s 2018/19 Improvement Plan and the System Level Measures continue to track favourably. The
alliancing approach to healthcare in Canterbury is well established and embedded in developing system
improvement, evidenced by the direct collaboration with over 60 people from across the Canterbury health system
in the development of this plan. The System Level Measures Framework naturally falls into supporting key activities
occurring to reduce modifiable determinants that influence inequitable health outcomes and access to health
services.
Annual re-development of the System Level Measures Framework is enabled through the Service Level Alliances
and Workstreams in which relevant stakeholders including our clinical teams from across the system, collaborate
to lead changes in the way services are delivered. This alliance approach enables connections across the system to
result in identification of actions to improve and track performance towards achieving better health outcomes for
the community.
With the System Level Measures Framework now established within Canterbury’s way of working, over the next 12
months a greater focus will be strengthening our focus on achieving equitable outcomes for all population groups.
During the year an equity lens will be placed on contributory measures through work to understand the variance in
ethnicity capture. This framework provides a way to prioritise, resource and evaluate services based on equitable
targets. Our aim is to grow and strengthen this approach year on year.
Key changes in our 2019/20 Improvement Plan include updating the Actions to Improve Performance, and refining
some contributory measures within Amenable Mortality, and resetting the System Level Measures milestones. A
focus for selecting new Amenable Mortality contributory measures was to consider ethnic variation in the causes
of amenable deaths. We are pleased to continue demonstrating Canterbury Health System’s commitment to improving the health outcomes of our population through our collective identification of priorities, redesign of
services and implementation of transformation changes in the way health care is delivered through this Plan.
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MESSAGE FROM SIR JOHN HANSEN
ALLIANCE LEADERSHIP TEAM CHAIR | CANTERBURY CLINICAL NETWORK
David Meates
Chief Executive Officer
Canterbury DHB
Peter Townsend
Chair
Pegasus Health
Charitable Ltd
Dr Lorna Martin
Chair
Rural Canterbury PHO
Dr Angus Chambers
Chair
Christchurch PHO
Canterbury continues to provide more integrated care provided as close to home as possible, which is a testament to all
those working within the health system either behind the scenes or face-to-face with patients and their whānau.
Our continued commitment to working collectively across the health system focuses on improving access to health
services based around what’s best for our community, and demonstrating our contribution to collectively agreed system
outcomes.
Our health system continues to face a number of challenges, and at the forefront of those is the challenge of ensuring
equitable outcomes for the most vulnerable members of our community, and those with the most need. This year our
alliance leadership, service level alliances, workstreams and service development groups are thinking deeply about how
best to achieve equity of access and outcomes for those that experience inequity and as part of our commitment and
responsibility to Te Tiriti o Waitangi.
As part of this, we’ve strived for an improvement plan that considers equity at the forefront of everything we do. This sees us shift focus in some key areas including updating of our contributory measures to consider ethnic variations in the
causes of amenable deaths.
I thank you all for your hard work and dedication to achieve milestones that enable system improvement for the
community.
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INTEGRATING THE SYSTEM LEVEL MEASURES FRAMEWORK INTO OUR HEALTH SYSTEM
Canterbury’s way of working brings together expert groups, including Service Level Alliances, Workstreams, and
workgroups within the Canterbury Clinical Network Alliance with the aim of leading change in health services that
improve the health outcomes of our population. Typically these groups include urban and rural clinicians who
participate in the services, people that bring consumer, Māori, Pacific and rural perspectives, and management
from the relevant organisations.
An expert group has been identified to lead each of the System Level Measures contributory and system measures
and associated activity. A table illustrating which expert group(s) are leading each of the contributory measures is
included in Appendix One. Also shown in this table are the expert groups that link with and/or support this activity.
A System Outcomes Steering Group involving clinical leaders from across the system, public health experts, quality
improvement staff, analysts and planners is in place to guide Canterbury’s ongoing development of the System
Level Measures framework. Figure 1. Illustrates the roles of this Steering Group and various expert groups.
Figure 1: Summary of the role of the System Outcomes Steering Group and the expert groups leading each contributory measure.
Expert groups including SLAs and workstreams within the
Alliance
Access and analyse the relevant data;
Agree on specific actions to achieve the priorities and
establish an annual work plan;
Progress any service redesign or development
required; and
Monitor / report on their work plan including the
actions contributing to improvements in the measures.
The System Outcomes Steering Group
Oversees and monitors Canterbury’s response to the System Level Measures;
Analyses the national and local data;
Refines Canterbury’s priorities and contributory measures;
Identifies the expert groups best placed to champion
the measures; and
Leads the communication / engagement of providers
across the system in a collective system wide response.
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KEY ACHIEVEMENTS
Significant progress has been made towards the Actions to Improve Performance identified in Canterbury’s 2018/19
Improvement Plan. A snapshot of some key achievements are highlighted below.
Ambulatory Sensitive Hospitalisation (ASH) Rate for 0-4 Year Olds
Projects have been developed throughout the year with the aim to reduce ASH rates. One project involves the
development of a process to refer children attending ED and/or Children’s Acute Assessment to a Whānau Ora navigator. The other project set for a trial over winter 2019 is to offer free care at After Hours for Māori and Pasifika children if there is no space at their enrolled general practice.
Acute Hospital Bed Days
Work has occurred across the system impacting upon acute hospital bed days. Highlights include:
Increased focus on delivery of services that align with Pasifika view of health. To support this work the DHB and
Pasifika Futures jointly appointed a Pasifika Portfolio Manager.
StrokeViewer software tool was developed to incorporate community data to provide an overview of the
journey for Stroke and Other Cerebrovascular patients’ in-hospital stay and rehabilitation on discharge.
Education within primary care completed to encourage team work and address inappropriate polypharmacy
that leads to admissions.
New rural models of care to improve service and sustainability were developed. This includes the development
of a collaborative after hours arrangement across five practices and St John in Hurunui.
Patient Experience of Care
Pilots to increase the reach of patient experience surveys were completed in Outpatients and Paediatrics wards.
The success of these pilots has resulted in the survey continuing to be offered for these patients in 2019/20.
Additionally the inpatient patient experience survey sample size was successfully increased, with a
recommendation made to send the inpatient survey to all eligible inpatients.
Amenable Mortality
The Population Health and Access Service Level Alliance and Canterbury Clinical Network won the Improved Health
and Equity for All Populations category at The People’s Choice Awards for developing the Motivational Conversations programme that increased interpersonal communication skills between patients and primary health
care providers. This module is now offered on an on-going basis and involves the three PHOs. As this is now business
as usual it has been removed from the SLM Improvement Plan as a contributory measure.
Youth Access to Health Services
The Oral Health Service Development Group is now ready to develop the next stage of improving youth access to
dental services. This has resulted in the development of a new contributory measure to deliver the service
identified as needed by youth consulted with during 2018/19.
Babies Living in Smokefree Homes
The number of pregnant women enrolling with smoking cessation services and remaining smokefree at the four
week follow-up is remaining fairly static. During 2019/20 we will be strengthening the pathway and incentive for
pregnant women to attend a smoking cessation consultation through linking this to our Sudden Unexpected
Death in Infancy (SUDI) safe sleep programme.
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CANTERBURY’S SYSTEM LEVEL MEASURES FRAMEWORK The diagram below demonstrates Canterbury’s System Level Measures Framework. In the centre are the System Level Measures and circling those are the locally-selected contributory measures. Further detail on each
contributory measure is provided below.
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HOW IT ALL FITS TOGETHER
The Canterbury Health System has tracked performance of our increasingly integrated and patient-centred
approach through the Canterbury Health System Outcomes Framework since 2013. The System Level Measures and
contributory measures detailed in this Improvement Plan are integrated into our existing Outcomes Framework to
demonstrate their alignment with Canterbury’s approach. The measures identified in this document have been highlighted below within Canterbury’s Outcomes Framework to illustrate this alignment.
Canterbury Health System Outcomes Framework
System Level Measures Framework
The System Level Measures
contribute to Canterbury’s Outcomes Framework
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System level measure:
AMBULATORY SENSITIVE HOSPITALISATION RATE FOR 0-4 YEAR OLDS
CANTERBURY’S EXPERIENCE
Our priority is to reduce the ethnic variation in
the ambulatory sensitive hospitalisation (ASH)
rate between the Pacific and Total populations.
At September 2018 Canterbury’s ASH rate for 0-4
year olds of 6,142 per 100,000 population is
below the national average for the Total
population1. When viewed over the previous four
years, it has increased slightly over the previous
year.
Canterbury’s 0-4 year old ASH rate for the Pacific
population of 11,582 per 100,000 is higher than
the Total population rate; however Canterbury’s 0-4 year old ASH rate for the Māori population of 5,369 per
100,000 is lower than Canterbury’s Total population rate. Viewing Canterbury’s data by medical conditions illustrates:
The Upper Respiratory and Ear Nose and Throat (ENT) Infections category is the largest contributor to
Canterbury’s ASH rate, at 2,101 per 100,000 Population.
Canterbury’s 0-4 year old ASH rates for Upper Respiratory and ENT Infections and Lower Respiratory Infections
are higher than the national average.
In 2018/19 work was undertaken to reduce barriers experienced by some whānau in accessing health services that contribute to the ethnic variation in Canterbury’s 0-4 year old ASH rate. This includes review of 2018 Emergency
Department (ED) data to identify the number of ASH admissions that would be suitable for referral to a Whānau Ora navigator, and under development is a trial to offer free care at After Hours for Māori and Pasifika children if there is no space at their enrolled general practice.
We also continue to build upon and grow the LinKIDS child health coordination service. This is an initiative
developed in Canterbury. It is focussed on connecting children with health services, and ensuring children receive
services in a timely manner. It has three main focuses:
Connecting children to health services by enrolling infants in health services at birth, and ensuring that children
who move to Canterbury are also connected with these services.
Supporting families who are not engaging with health services including missed immunisation, oral health or
B4SC service, and timely Rheumatic Fever treatment.
Referral pathway to services such as Young Parents Support Service.
1 The National Minimum Data Set of ASH Rate for 0-4 year olds to December 2017 using the New Zealand Standard Population informed Canterbury’s analysis and establishment of the 2018/19 milestones.
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MILESTONE
Canterbury’s internal target is to reduce the Pacific inequity in ASH rates, however the relatively small number
of admissions and resulting inherent variation limits the viability of setting a numerical milestone. In addition,
analysis of the leading conditions contributing to the ASH rate confirms that influenza, gastro-enteritis
outbreaks and dental elective volumes have a significant influence on the yearly variation in ASH rate for 0-4
year olds across all populations. Acknowledging these challenges, the average ratio between the Total and
Pacific populations (Total rate:Pacific) has been selected as the soundest approach to setting a milestone2.
The small actual numbers involved with the Pacific ASH rate mean there is potential for large fluctuations
from quarter to quarter, for example, the addition of just 10 admissions changes the rate by 5% and increases
the ratio by 0.1. To reduce the effect of fluctuations due to the small Pacific population in Canterbury the
milestone has been calculated based on a four-year average.
The four year average for previous years has been 1:2.08 and 1:2.02. At this rate of reduction the four year
average in September 2019 will be 1:2.00. Over 2019/20 Canterbury will track and aim to reduce the average
ratio (Total rate:Pacific) over four years, to achieve a ratio of 1:2.00, or less, by 30 June 20203.
12 mo. to
Sep 2014
12 mo. to
Sep 2015
12 mo. to
Sep 2016
12 mo. to
Sep 2017
12 mo. to
Sep 2018
Forecast 12
mo. to Sep
2019 (forecast
based on previous
years)
Pacific Rate 2.33 1.96 2.10 1.94 2.07 1.90
4-year average 2.08 2.02 2.00
CONTRIBUTORY MEASURES
ASH RATE – VARIATION BETWEEN POPULATIONS
Outcome sought: Understand the variation that exists between the Canterbury Total and Canterbury Pacific
populations, with a focus on the ASH admissions for 0-4 year olds coded with Upper and ENT Respiratory
Infections.
Rationale for selection: A variation in the ASH rate for 0-4 year olds exists between the two population groups.
This is evident in the Diagnosis Related Group (DRG) category Upper and ENT Respiratory Infections which is the
single largest contributor to the ASH rate for 0-4 year olds and is above the national average. While the
September 2014 ratio between the Total and Pacific population of 1:2.34 has decreased to 1:1.57 in September
2018, true progress will be achieved through monitoring our progress over an extended period of time to account
for inherent variation.
2 Target setting for ASH rates is difficult due to the uncertainty around projecting future rates, based on the inherent variability of events in a relatively small
population. For the 12 months to September 2014, the ASH rate for Pacific 0 to 4 year olds was 14,225 per 100,000 population, with a calculated 95%
confidence interval of 12,707 to 15,744; for the Total population the rate was 6,583, and the 95% confidence interval was 6,300 to 6,865. For the purposes of
projecting a future target, based on these data, the ratio of Pacific to Total ASH rates may lie between 1.85 (using the lowest extent of the 95% confidence
interval for Pacific and the highest for Total population) and 2.50 (using the highest extent of the 95% confidence interval for Pacific and the lowest for the
Total population). The ASH rates and the ratios therefore need to be interpreted with caution and looked at over a longer reporting period.
3 The September 2018 dataset was used to generate the milestone.
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Measure description:
The rate of 0-4 year olds admitted with a code of
Upper Respiratory and ENT Infections and the gap
that exists between the ASH rate for 0-4 year olds
in Canterbury’s Pacific and Total populations. Numerator: The number of ASH admissions for 0-4
year olds coded with Upper and ENT Respiratory
Infections.
Denominator: The number of 0-4 year olds.
Data source: Ministry of Health data released
quarterly.
ORAL HEALTH
Outcome sought: An increase in the number of children who are caries free at five years of age.
Rationale for selection: Dental conditions are the fourth largest contributor to Canterbury’s ASH rate for 0-4
year olds with a rate of 532 per 100,000 at September 2018. In addition, there is local variance between
population groups in both caries free and enrolment in the Community Dental Service. This measure has been
selected from a number of oral health / child health indicators, including the enrolment of children in the wider
health services. It should be noted that Canterbury currently does not add fluoride to its water supply, unlike
many other North Island metropolitan areas.
Measure description: The percentage of children
caries free at five years of age.
Numerator: At the first examination after the
child has turned five years, but before their sixth
birthday, the total number of children who are
caries free (decay or filling free).
Denominator: The total number of children who
have been examined in the five-year-old age
group, in the year to which the reporting relates.
Data Source: Community Dental Service.
INCREASED ACCURACY OF ETHNICITY CAPTURE
Outcome sought: Increase the accuracy of ethnicity capture of new borns enrolled in general practice.
Rationale for selection: The collection of robust quality data enables the monitoring of access rates and results by
ethnicity; this in turn supports improved health planning and design and delivery of services aimed at reducing health
inequities. Any inaccurate capture of ethnicity at birth follows the new born’s registration into other services.
Measure description: This measure requires further analysis to identify the contributors of the inaccurate
ethnicity capture, the subsequent actions required and the key metric for monitoring change. In the interim, the
new borns enrolled in a PHO within three months by ethnicity illustrated below, will be monitored.
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INCREASED NEWBORN ENROLMENT
Outcome sought: An increase in the number of
new borns enrolled in general practice.
Rationale for selection: Early enrolment in
general practice and the wider health services
(including Well Child Tamariki Ora and the
Community Dental Service) is a foundation for
patients accessing health care. There is
variability in the new born enrolment coverage,
most noticeably in the Pacific population.
Measure description: The percentage of new
borns enrolled with a PHO within three months.
Numerator: Number of infants under three months enrolled with a PHO.
Denominator: Number of births reported to the National Immunisation Register. Note the register includes all
babies born in Canterbury, some of whom are not from our region.
ACTIONS TO IMPROVE PERFORMANCE: ASH RATE FOR 0-4 YEAR OLDS
Contributory
Measure Actions to Improve Performance Responsibility
ASH Rate Provide general practices with data of their enrolled 0-4 year olds
who are admitted to hospital with an ASH event.
Develop and implement a scheme where children can be seen for
free at After Hours during the day if their own practice does not
have an appointment available.
Develop and implement a process to refer children admitted with
respiratory conditions for a healthy home check – reducing damp,
smokefree etc.
Investigate the feasibility of implementing a targeted pertussis
and influenza vaccination programme for pregnant women, and
influenza vaccination for 0-4 year olds with chronic respiratory
conditions, with a focus on Māori and Pacific.
A project group within
the Child and Youth
Workstream
Oral Health Work with community dental services to develop a recall system
targeted at need and identified risk.Develop a programme that
strengthens caregivers of children aged 0-2 years understanding of
oral health.
Oral Health Service
Development Group
New Born
Enrolment
Implement the process to ensure children not enrolled in general
practice are supported to be enrolled.
Immunisation Service
Level Alliance and
PHOs
Increased
Accuracy of
Ethnicity
Capture
Continue training all midwives with a focus on new and
community midwives on the 2017 Ethnicity Data Protocols to
increase the accuracy of ethnicity recorded in Maternity Hospital
Specialist Services.
Immunisation
Manager and PHOs,
Māori and Pacific
Reference Groups
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System level measure:
ACUTE HOSPITAL BED DAYS
CANTERBURY’S EXPERIENCE 4
Our priority is to further reduce the acute hospital bed day rate for the Total population, while optimising
hospitalisation for all ethnic groups.
Averaged over the three years to December 2018,
Canterbury DHB’s Age Standardised Acute Bed Day rate of 293 per 1,000 population was 5%
lower than the New Zealand Total rate of 308 per
1,000. Viewed by ethnicity5, averaged over the
three years Canterbury’s Standardised Acute Bed Day rates for the Māori population (321 per
1,000) and Pacific population (448 per 1,000) are
higher than Canterbury’s Total Acute Bed Day rate; while the Other population rate is the same
at 293 per 1,000 population.
Māori and Pacific perspectives are an embedded part of Canterbury’s Alliance; membership across expert groups and Reference Groups offer guidance in all aspects of service design and redesign.
Over 2018/19 work continued to implement innovative approaches to the funding and the delivery of health
services that align with a Pasifika view of health. To support this work, a Pasifika Portfolio Manager was jointly
appointed by the DHB and Pasifika Futures.
Viewing Canterbury’s data by medical conditions illustrates that the Stroke and Other Cerebrovascular Disorders category remains the largest contributor to Canterbury’s Acute Bed Day rate at 21 per 1,000 population, and is higher than the national average of 17 per 1,000. In 2018/19 a software tool StrokeViewer was developed to
incorporate community data to provide an overview of the journey for Stroke and Other Cerebrovascular patients’ in-hospital stay and rehabilitation on discharge. During 2019/20 the focus will continue on improving flow through
acute and rehab services.
During 2018/19 the Polypharmacy working group continued to facilitate improvement across the system by
convening small group education within primary care. This education involved clinicians from across services
(nursing, general practice and pharmacy) learning together and has enabled teamwork between professions to
address inappropriate polypharmacy that leads to admission. Also underway is the development of a pathway for
referring falls patients for a Medication Therapy Assessment (MTA). While there has been secondary care
4 The National Minimum Data Set Acute Hospital Bed Days to December 2018 (using Age Standardisation to the WHO 2000 Standard Population) was used to
inform Canterbury’s analysis and establishment of the 2019/20 Milestones. 5 The National Minimum Data Set Acute Hospital Bed Days to December 2018 (age standardised using WHO 2000 Population Standard) by prioritised ethnic
groups
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representation on the Polypharmacy group, need for a larger secondary care team has been recognised, to work
on improvement specific to secondary care. During 2019/20 we will work towards a combined approach for the
broader and secondary care polypharmacy groups where appropriate.
Over the last three years a number of Canterbury’s rural communities have developed new models of care that
identify opportunities for service improvements while ensuring the sustainability of rural health services. In 2018/19
the implementation of the Hurunui and Oxford Models of Care resulted in a collaborative after-hours arrangement
across five general practices and St John being established in the Hurunui region, protocols for local observation
services being developed, and support provided to general practice for stabilising patients while awaiting their
transportation to hospital. In 2019/20 this work will continue and include further work on a restorative community
service. By assisting people to access these services locally, these initiatives will contribute to optimising
Canterbury’s Acute Bed Day rate.
Our Acute Demand Programme contributes to a reduction in acute hospital bed days through various initiatives,
these include, but are not limited to:
Packages of care funding for general practice by providing non-specific funding for 3-5 days with the express
purpose of keeping patients out of hospital where possible. This funding allows for long consultations, repeat
visits and in-practice observation.
Acute nursing to support patients both in clinic and at home, primarily supporting those with skin and soft
tissue infections, discharge support in the home including heart failure/frailty monitoring and respiratory
conditions.
In hospital liaison that identifies patients suitable for supported discharge from all hospital wards and ED.
An observation unit at the 24 Hour Surgery that takes patients from general practice and the 24 Hour Surgery.
Average admission times are 4-6 hours, but up to 24 hours is possible.
Pegasus Health Acute Demand Nursing Team support for heart failure patients in the transition from hospital
to home. This team provides daily home visits with medication review, nursing assessment and medication
titration for up to seven days.
Another initiative of the Acute Demand Programme was to provide different approaches to support people with
COPD during flare-ups by using community and ambulance services more effectively. One outcome of this has been
to reduce the number of admissions and time spent in hospital, reducing occupied bed days for COPD from an
average of 13.7% in the three years to 2012, to an average of 9.3% over 2016 to 2018. Over the six years of the
COPD initiative there have been nearly 900 fewer admissions, 1,200 fewer ambulance arrivals at ED after hours,
10,000 fewer bed days and 300 fewer acute readmissions compared with what would be expected if system changes
were not made.
Likewise the community falls prevention programme for those aged 75+ continues to contribute to a reduction in
acute bed days. In the six years of the programme running there have been approximately 2,600 fewer ED
attendances, 800 fewer fractured neck of femur (NOF), 51,000 fewer NOF bed days and 300 fewer deaths at 180
days compared to if the programme was not implemented.
MILESTONE
Despite Canterbury’s Acute Bed Day rate being significantly below the national average, further reducing this rate
is a high priority for Canterbury to manage its population within a constrained bed supply that will continue, even
after the new Acute Services Building opens in 2019/20. Higher than projected population growth is anticipated to
place pressure on Canterbury’s inpatient capacity with system-wide efforts underway to manage the demand on
hospital services.
In this context, work to reduce the ethnic variation in the Acute Bed Day rates is being progressed alongside a focus
(and setting of a milestone) on Canterbury’s Total Acute Bed Days rate. Canterbury considered setting a milestone
based on the ethnic variation between the Māori, Pacific and total population, however it is unclear what ethnic
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variation is appropriate. Striving for equivalent acute bed day rates across all ethnicities may lead to Māori and Pacific populations who have a higher burden of disease not receiving optimal access to acute hospital care. In
seeking equitable health outcomes Canterbury will work towards appropriate hospitalisation for all ethnicities.
Finally, in the process of establishing an achievable milestone for 2019/20, further analysis of Canterbury generated
data on Acute Bed Days was undertaken including consideration of the admitting medical conditions and how
amenable they were to change. Grouping the Acute Bed Days into those amenable to change (Medical, Surgical and
Rehabilitation admissions) and non-amenable (Mental Health and Maternity admissions) highlighted that a realistic
milestone would be based on 85% of the total Acute Bed Days. While this approach could not be replicated using
the National Service Framework Library data set, these local calculations continue to inform the setting of
Canterbury’s milestone.
The Canterbury Health System’s agreed milestone for June 2020 is to reduce the Acute Bed Days rate to 280 per
1,000 population or less.6 This has been generated using Canterbury’s Acute Bed Days average over the three
years to December 2018. It is noted that within this longer-term trend, the Acute Bed Days rate will be influenced
by external factors such as the severity of the influenza season.
CONTRIBUTORY MEASURES
REDUCED LENGTH OF STAY FOR ACUTE ADMISSIONS
Outcome sought: To reduce the number of occupied bed days following an acute admission while ensuring patients
receive clinically appropriate care during their hospital stay and after discharge, to avoid a readmission.
Rationale for selection: Canterbury’s investment in primary care and work on condition specific pathways has
supported an overall reduction in the acute phase of hospital stays. At September 2018 Canterbury’s standardised average length of stay of 2.37 bed days is below the New Zealand average stay of 2.49 bed days.7
Measure description: The number of beds
occupied for greater than 14 days following
an acute admission. Note patients coded as
Mental Health and Maternity are excluded.
While a number of measures will be
monitored locally as indicators of the length
of stay for acute admissions, this measure is
considered a key metric for monitoring
change.
Data source: Local data generated through
Signals from Noise (SFN).
6 Milestone set using the National Minimum Data Set Acute Hospital Bed Days to December 2018 (age standardised using WHO 2000 Population Standard) by
prioritised ethnic groups. The previous three years (December 2016-18) Total rate was averaged to develop the milestone for June 2020. 7 National Minimum Data Set Inpatient Average Length of Stay (OS3) at September 2018 (standardised on age, sex, ethnicity, rurality, deprivation, acuity,
primary diagnosis, secondary diagnoses, comorbidity/complexity, operations, external cause codes)
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MONITOR ACUTE READMISSIONS
Outcome sought: That people receive effective (and safe) treatment in our hospitals, as well as appropriate support
and care on discharge.
Rationale for selection: Measures of readmission rates are important balancing metrics for the reduced length of
stay for acute admissions. Monitoring the rates at different times post-discharge provides a more comprehensive
picture of factors contributing to readmissions, and better informs the response required.
The selection of both the 3 day and 28 day readmission rates as contributory measures provide appropriate
balancing metrics. The contributors to the readmission rates are multifaceted. Based on current knowledge, it is
proposed that an acute readmission to hospital within 3 days may be an indicator of a ‘failed discharge’. Any increase in this rate would suggest further exploration into discharge timing, planning and its implementation, and
patient readiness was required. While an increase in the 28 day readmission rate could be driven by an additional
number of factors; with further investigation into contributors such as patients’ access to services, the disease process, the integration and coordination of primary care and community services required.
Measure description: Monitor
Canterbury’s acute readmission to hospital within 3 days.
Numerator: Canterbury’s average
number of acute readmission stays in
hospital within 3 days for a medical or
surgical admission.
Data source: Local data generated
through SFN.
Measure description: Monitor
Canterbury’s acute readmission to hospital within 28 days.
Numerator: Canterbury’s average
number of acute readmission stays in
hospital within 28 days for a medical
or surgical admission.
Data source: Local data generated
through SFN.
REDUCTION IN FALLS
Considerations for this measure: In October 2018 Christchurch Hospital Campus and Ashburton Hospital
successfully went live with SI PICS (for all services except maternity which is scheduled for early 2019). SI PICS
works in conjunction with the existing South Island-wide clinical portal Health Connect South and is a step
closer to the vision of a fully integrated electronic patient record. With more than one million patient records
transferred into the new patient management system we have experienced some unexpected challenges with
data quality. One of the key issues being faced is that during the migration to SI PICS a number of irregularities
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were exposed from the previous legacy systems, including historic workarounds to meet Ministry data
requirements.
As part of the move from PMS Homer to SI PICs, a new Emergency Department patient management system
was introduced called ED at a Glance (EDaaG). The EDaaG system changed the way falls are being recorded at
ED which has impacted on the reporting of results for the falls presentations. Work is under way to understand
the impact of this difference.
The sudden decrease from October 2018 in the graph on the next page is due to irregularities in the way results
are being reported.
Outcome sought: A reduction in the
number of acute admissions to
hospital following a fall for those
aged 65 years and over.
Rationale for selection: Hip and
Femur Procedures, Hip
Replacements, and Humerus, Tibia,
Fibula and Ankle Procedures, are in
the top fifteen DRG clusters8
contributing to Canterbury’s Acute Bed Days rate. A high proportion of
patients entering rehabilitation
(which is generally a longer component of a patient’s overall stay) have a primary code of femur, humerus and
other fractures. Given Canterbury’s ageing population, reducing the harm from falls will reduce the fracture related demand on acute services and help people to stay well and independent in their own homes, whilst
maintaining quality of life.
Measure description: A decrease in the number of acute admissions against a forecasted pre-intervention
trend of the number of acute admissions to hospital following a fall for those aged 65 years and over.
Data source: Local data generated through SFN.
POLYPHARMACY
Outcome sought: Prevention of, or a reduction in, the risks associated with polypharmacy.
Rationale for selection: The appropriate prescribing and dispensing of medications for people aged 65 years
and over will support improved health outcomes for older people, which is important for the Canterbury
Health System given its aging population. This measure is also an indicator of integration across general
practice, community pharmacy, and hospital care.
Note: It is acknowledged that while any medication therapy assessment will determine the appropriateness of
medications; it may not impact the number of medications being taken. The number of polypharmacy audits
completed and referrals for medication therapy assessments will be monitored locally alongside the rate of
people aged 65 years and over on 11+ medications.
8 Top 15 Grouped by the Highest Case Weighted Hospital Event within each Acute Stay at March 2018 (WHO 2000 Population Standard).
17
Measure description: The rate of people
dispensed with 11 or more long term
medications.
Numerator: The count of patients aged 65
years and over who have been dispensed 11
or more distinct chemicals in two
consecutive quarters.
Denominator: The count of the DHB
population that is aged 65 years and over.
Data source: The Health Quality and Safety
Commission (HQSC) Atlas of Variation.
ACTIONS TO IMPROVE PERFORMANCE: ACUTE BED DAYS RATE
Contributory
Measure
Actions to Improve Performance Responsibility
Reduced Length
of Stay
Use data collected from StrokeViewer to develop an early
supported discharge model for stroke patients.
Participate in national benchmarking for community stroke
rehabilitation services using Ambulatory AROC data.
Adult Rehabilitation
Steering Group.
Monitor Acute
Readmissions
Continue to monitor the number of readmissions as a
balancing metric alongside the implementation of changes in
patient pathways and length of stays.
Urgent Care Service
Level Alliance
Minimise Harm
from Falls
Maintain access of people aged 75+ in Canterbury to the Falls
Prevention Programme following a fractured neck of femur.
Improve access to, and attendance at Community Based
Strength and Balance classes in Canterbury.
The Falls and Fracture
SLA
Polypharmacy Further develop general practices capability to view their
enrolled patients on multiple medications, including by
ethnicity.
Promote audit and review capability of patients on multiple
medications to general practices.
Monitor polypharmacy patterns in Canterbury including by
age band and ethnicity.
Complete implementation of the process for patient referral
from the Falls Prevention Programme for a medication
review, and vice versa.
Provide information to the public on Choosing Wisely for
medicines with their doctor and pharmacist through
increasing general practice and community pharmacy
knowledge of Choosing Wisely.
An expert project group
convened by the Clinical
Quality Education Team
and the Pharmacy
Service Level Alliance.
System Level
Measure
Build partnerships to support Pasifika Futures Limited to
implement primary healthcare services that improve
Canterbury Pasifika health.
Canterbury DHB, PHOs
and Pasifika Reference
Group
18
Implement innovative approaches to the funding and
delivery of health services for Pasifika peoples through work
with Pasifika Futures Limited.
System Level
Measure
Implement agreed principles of restorative home-based care
in Hurunui and Oxford for rural people to support discharge
and/or restored function following a period of illness.
Confirm protocols, entry criteria and clinical responsibility,
and handover to enable the trialling of an observation
service in a rural location.
Rural Health
Workstream
19
System level measure:
PATIENT EXPERIENCE OF CARE
CANTERBURY’S EXPERIENCE
Our priority for Patient Experience of Care is to facilitate optimal use of information from the in-hospital and
primary care patient experience surveys to drive quality improvement.
In-Hospital Patient Experience Survey
Canterbury’s results from the four domain overall questions are consistently at or above the New Zealand average results9.
Domain – Overall Question
Canterbury weighted average score
out of 10 for
Q1 2017 – Q4 2018
NZ weighted average score out
of 10 for
Q1 2017 – Q4 2018
Communication 8.4 8.4
Coordination 8.5 8.4
Partnership 8.6 8.5
Physical & Emotional Well-being 8.7 8.7
Canterbury DHB Adult In-Hospital Survey Results (Q1 2017 – Q4 2018), Health and Quality Safety Commission
Over the last 12 months, work has been undertaken to increase the sample size and quantity of feedback
contributing to Canterbury’s results. A trial was run sending the survey to 1,000 patients fortnightly. The success
of this trial has resulted in the recommendation that the survey is now sent to all patients who qualify.
Outpatient Patient Experience Survey
During 2018 an outpatient survey was implemented as a trial in Ashburton, Burwood and Christchurch Women’s Hospitals. After successful implementation in these areas, the outpatient survey is expected to be available for
Christchurch Hospital outpatients during 2019-20.
Paediatric In-Hospital Patient Experience Survey
The South Island Alliance and the Paediatric Society of New Zealand trialled an interactive application (app)
featuring an animated frog (Fabio) to encourage children and young people from six to 16 years to provide
feedback regarding their inpatient hospital experience in the Paediatric wards. Children and parents were invited
to provide feedback during their stay with a kiosk available 24 hours a day. The app also features an email facility
where a survey link is sent to parents after their child is discharged. The app has yielded on average more monthly
feedback than the traditional suggestions, compliments and complaints boxes. The trial will continue during 2019.
Primary Care Patient Experience Survey
Canterbury’s results from the four domains are at or above the New Zealand average results for the 12 months of
2018.
9National Adult Inpatient Experience Results for Patients Treated in November 2018.
20
Domain – Overall Question Canterbury average score out of
10 for 2018
NZ average score out of 10 for
2018
Communication 8.4 8.4
Coordination 8.4 8.5
Partnership 7.6 7.6
Physical & Emotional Well-being 7.8 7.8
Canterbury Patient Experience Survey Results (Jan - Dec 2018), Health and Quality Safety Commission
In December 2018, 85 (74%) of Canterbury’s 115 general practices obtained feedback from their patients using the
Patient Experience Survey, up from 71 (62%) of 115 practices in February 2018. Canterbury’s response rates to the survey aligns with national levels of response
Over the next 12 months our priority will be to improve understanding of questions within the survey to enable
local response to low scoring areas to occur. Alongside this we will continue to increase the number of general
practices accessing feedback from their patients using the Patient Experience Survey.
MILESTONE
In-Hospital Patient Experience Survey
Construction of new facilities is nearing completion with migration of some services to new buildings underway,
and to continue throughout the year. These changes are likely to impact on patients’ experience of care,
maintaining the inpatient survey results at 30 June 2020 will locally be considered a significant achievement.
Primary Care Patient Experience Survey
In 2018/19 the number of general practices using the Patient Experience Survey to access feedback from the
enrolled population continued to increase (55% in December 2017 to 74% in December 2018). In 2019/20
Canterbury will continue to embed the use of the data collected to inform and drive quality improvement.
Quality improvement relies on making data analyses available to people providing care: translating data into
information that creates a platform upon which people can act. It is difficult to set a numerical measure that
indicates progress on using data to drive quality improvement. Canterbury has selected a milestone to improve the
score for sub-questions relating to medications in the Communication domain:
Were you told what to do if you experienced side effects? Improvement in average 12 month10 score from
6.8/10 to 6.9/10 or more.
Were the possible side effects of the medication explained in a way you could understand? Improvement in
average 12 month score from 7.5/10 to 7.6/10 or more.
Were you told what could happen if you didn’t take the medication, in a way you could understand? Improvement in average 12 month score from 7.5/10 to 7.6/10 or more.
10 The 12 month period of 01/01/2018 to 31/12/2018 was used to calculate the average score for the sub-questions.
21
It is acknowledged that the influences on patient experience are complex. It will take sustained efforts to improve
this and is likely to take more than the year of the improvement plan. The ongoing programme of work will be
focussed on quality improvement through education and administration.
CONTRIBUTORY MEASURES
IN-HOSPITAL SURVEY RESPONSE RATE
Outcome sought: An increase in the proportion of adults completing the in-hospital survey.
Rationale for selection: Canterbury’s Survey response rate was historically lower than the national rate. Improvements over 2016 reflect the increased focus on capturing patients’ email addresses, allowing communication of the survey to them. During 2017 Canterbury merged fortnightly survey data collected locally
with the quarterly national collection to increase the number of respondents contributing to the results. While this
initially improved the In-Hospital Survey response rate, during 2018 a process to systematically capture patients’ email addresses as business as usual was implemented. It is anticipated that this will improve response rates over
the long term, however a new patient management system is yet to have patient email address information
migrated into it. While this is unlikely to affect response rate, it may initially impact the survey sample size.
Measure description: The proportion of adult
inpatients who complete the survey.
Numerator: The number of hospitalised patients
aged 15 years and over who provided feedback
via the adult in-patient survey.
Denominator: The number of hospitalised
patients aged 15 years and over who are
surveyed.
Data source: The Health, Quality and Safety
Commission.
IN-HOSPITAL ENGAGEMENT OF FAMILY / WHĀNAU IN PATIENT CARE
Outcome sought: Patients experience increased engagement between hospital staff and their family/whānau in
discussions about their care.
Rationale for selection: Canterbury’s In-Hospital Survey result in this supporting question has historically been
lower than the national rate. The Always Events project is providing a framework for Canterbury to explore various
stakeholder perspectives of patient care, and through this understand and address the contributors to this result.
We are now in the second phase of the Always Events improvement project and this work will continue over
2019/20.
22
Measure description: To better understand what
influences the score on the In Hospital Survey
result for the supporting question “Did the hospital staff include your family/whānau or someone close to you in discussions about your
care?”
Numerator: The sum of the weighted average
scores out of ten for this question response.
Denominator: The number of responders that
answered this question.
Data source: The Health, Quality and Safety
Commission.
PRIMARY CARE PATIENT EXPERIENCE SURVEY IMPLEMENTATION
Outcome sought: An increase in the proportion of general practices obtaining feedback from patients via the
Primary Care Patient Experience Survey.
Rationale for selection: PHOs continue to have an important role in working with general practices to increase the
number obtaining feedback from their enrolled populations. In 2019/20 Canterbury will continue to focus on
general practice’s engagement with the survey. Alongside this, the Primary Care Patient Experience Survey will
focus upon building understanding of sub-questions relating to Care Plans to enable the development of actions
to improve patient experience in this area.
Measure description: The proportion of
Canterbury general practices participating in
obtaining feedback from patients via the
Primary Care Patient Experience Survey.
Numerator: The number of general practices in
Canterbury participating in obtaining feedback
from patients via the Primary Care Patient
Experience Survey.
Denominator: The number of general practices
in Canterbury.
Data Source: Reported quarterly by the PHOs.
ACTIONS TO IMPROVE PERFORMANCE: PATIENT EXPERIENCE OF CARE
Contributory
Measure Actions to Improve Performance Responsibility
In-Hospital Survey
Completion Rate
Implement a process to survey all in-patients of
Christchurch Hospital who meet survey criteria.
Contribute to the working group developing email as a
preferred communication method via Health Connect
South.
DHB Quality & Safety
staff
In-Hospital
engagement of
family /whānau in care.
Continue with Phase Two of the national Always Events
pilot including work to:
o Clarify the role of the patient’s nominated
contact person.
DHB Quality & Safety
staff
23
o Develop education tools for staff, patients and
families.
o Test the process in one area and evaluate.
o Post evaluation test in three further areas.
Primary Care Patient
Experience Survey
Implementation
Work with general practice to increase the proportion
obtaining feedback from the Patient Experience Survey.
Assist general practice teams to interpret and use Patient
Experience Survey results as part of their ongoing quality
improvement.
PHO Quality & Safety
staff
Response Rate Monitor the Primary Care Patient Experience Survey
response rate by different population cohorts.
Monitor data in relation to Primary Care survey
respondents by age bands and ethnicity to identify
population cohorts that are underrepresented.
Identify and collaborate with working partners to promote
the Primary Care survey with population cohorts that are
underrepresented.
DHB and PHO Quality
& Safety Project
Group staff
In-Hospital &
Primary Care Patient
Experience Survey
Identify a common theme across the In-Hospital and
Primary Care surveys and progress a local targeted
response.
DHB and PHO Quality
& Safety Project
Group staff
Improvement in
Patient Experience
through increased
utilisation of patient
feedback.
Use information from the In-Hospital and/or the Primary
Care Patient Experience Survey to inform the work of
alliance groups in leading changes to the development and
delivery of health services.
Build understanding of sub-questions to enable the
development of actions to improve patient experience in
this area.
DHB and PHO Quality
& Safety Project
Group
Quality Improvement
through an increase
in domain question
scores.
Further embed utilisation of the Patient Experience Survey
information in Canterbury’s education programme and/or other education opportunities.
Share good practise via a case study to highlight the use of
survey results in change of general practice.
Promote the Patient Experience Survey (primary and
inpatient) in public publications (eg. Online, Well Now
magazine).
DHB and PHO Quality
& Safety Project
Group staff
24
System level measure:
AMENABLE MORTALITY
CANTERBURY’S EXPERIENCE
Our priority is to continue to decrease the amenable mortality rate.
Canterbury’s Amenable Mortality age standardised rate for under 75-year-olds is trending downwards. While it
remains lower than the total New Zealand rate, the gap between the Canterbury and national rates has narrowed
in recent years11. The national data provided by ethnicity indicates that both Māori and non-Māori non-Pacific
populations in Canterbury have rates lower than the New Zealand rates in 201512. When data are aggregated for
2011 to 2015 the Māori (163 vs. 202) and Pacific (185 vs 190) amenable mortality rates are lower than the national
rates, but the rate non-Māori non-Pacific (81 vs 77) population is higher. In the same data Canterbury has the fifth
lowest Māori amenable mortality rate among 18 DHBs and the sixth lowest Pacific rate among 11 DHBs.
The ratio of the Māori to the non-Māori non-Pacific rates has historically been lower in Canterbury than nationally,
however the national rate will possibly be lower than Canterbury within the next year. Refreshing some of our
Amenable Mortality contributory measures, with a focus on measures that are inequitable for Māori is expected to improve amenable mortality for Māori in Canterbury over time.
A review of the longitudinal Amenable Mortality data by cause of death identifies that a number of medical
conditions contributing to Canterbury’s Amenable Mortality Rate could be responsive to interventions that increase physical activity, improve nutrition and reduce smoking.
11 National Minimum Data Set Amenable Mortality – Final Data to March 2015 12 A standardised rate per 100,000 for Canterbury Pacific people is unable to be determined due to the small number of Canterbury Pacific people recorded in
this cohort.
25
During 2018/19 analysis was undertaken on the ethnicity, rate, age of death, and magnitude of trend, within each
potentially amenable condition. Findings from this analysis has been used to inform the selection of new
contributory measures and actions for 2019/20 where the aim is to reduce inequities.
MILESTONE
The Canterbury Health System’s agreed milestone is to maintain the current downward trend over time in the overall Amenable Mortality Rate. Applying this approach results in a milestone for the Amenable Mortality Rate at
30 June 2020 of 83 per 100,000 population. Additionally we aim to reduce the ratio between Māori and non-Māori non-Pacific to be lower than the 2015 ratio of 2.38.
CONTRIBUTORY MEASURES
The contributory measures selected include a focus on achieving equitable outcomes across ethnic groups. These
measures and the underlying actions are seen as being fundamental to reducing the impact of high and inequitable
rates of cancer morbidity and mortality among Māori. In addition, two measures of smoking prevalence are added
as indicators of Canterbury’s progress towards being Smokefree in 2025.
INDICATORS OF HEALTH PROMOTING LIFESTYLE
Outcome sought: An increase in factors that protect
health and reduction in risk factors in our population.
Rationale for selection: A range of services are
available to support our population in taking up
healthier behaviours. Increasing referrals to these
services is an indicator of our health system assisting
patients to navigate and access this support.
Measure description: Two measures; Green
Prescription referrals and enrolments in Te Hā –
Waitaha / Stop Smoking Canterbury service, have
been selected as indicators of people accessing a
wider range of lifestyle support services.
Data source: Provider data collected locally
26
Measure description: Te Hā – Waitaha Stop Smoking
Services provides the majority of smoking cessation
services in Canterbury. In 2019/20 it is expected that
only one of Canterbury’s PHOs will continue to
provide their enrolled population with access to their
own comprehensive smoking cessation support. To
monitor all smoking cessation activity across
Canterbury, enrolments in the PHO smoking
cessation services are combined with the Te Hā –
Waitaha activity.
Data source: Provider data collected locally.
MEASURE OF REGULAR SMOKERS IN CANTERBURY
Rationale for selection: Smoking is a major contributor to amenable mortality as a risk factor for many including
cancers, cardiovascular disease, stroke, chronic obstructive pulmonary disease, complications of the perinatal
period and sudden unexpected death in infancy. Reducing smoking through interventions in the health system
can therefore contribute to reduction in amenable mortality. Two indicators of the proportion of Canterbury’s population that are smokers are included below.
Outcome sought: A decrease in regular smokers to
5% prevalence in 2025.
Measure description:
The proportion of the Canterbury population who
are regular smokers.
Numerator:
For each ethnic group, regular smokers are people
who actively smoke one or more manufactured or
hand–rolled tobacco cigarettes per day.
Denominator:
Census usually resident population, by ethnicity.
Data source:
Statistics New Zealand Census 1996, 2006, 2013
data, with projections of the reduction in regular
smokers needed for the proportion of regular
smokers to be 5% for all ethnic groups by 2025.
27
Measure description: The proportion of the PHO
enrolled population aged between 15 – 74 years of
age that are recorded as a current smoker.
Numerator: The number of the PHO enrolled
population aged between 15 – 74 years of age
recorded as current smokers.
Denominator: The number of the PHO enrolled
population aged between 15 – 74 years of age.
Data source: Ministry of Health.
Note: This measure only captures people who are
enrolled in a PHO. As PHO enrolment for Māori is lower (around 80-85% in recent quarters) than other
ethnic groups (around 94-97%) this measure may
under or over-represent current smokers who identify
as Māori.
IMPROVED PHYSICAL HEALTH FOR PEOPLE EXPERIENCING MENTAL HEALTH AND/OR ADDICTION
ISSUES
Rationale for selection: People experiencing mental health and/or addiction issues tend to have worse physical
health outcomes and reduced life expectancy overall than their peers. Equally Well13 is a programme of
collaborative action to address poor physical health outcomes and reduced life expectancy of people experiencing
mental health and/or addiction issues. The delivery of Equally Well Consults in 2018-19 enabled people with mental
health problems to access wellbeing support through their general practice. In Canterbury, the Equally Well
Committee has collated a list of physical health programmes offered for people experiencing mental health and/or
addiction issues.14 The resource is intended for use by the sector to assist at-risk people access the appropriate
supports they need to help improve physical health and wellbeing.
Equally Well is an indicator of the additional mental health services being implemented in Canterbury to provide
at-risk people with timely access to the right care.
IMPROVED ACCESS TO CERVICAL CANCER SCREENING
Rationale for selection: Cancer morbidity and
mortality for Māori is high compared with other
population groups. Access to health services,
including screening programmes, have the potential
to reduce cancer mortality. Improving access to
cervical cancer screening, with a focus on Māori, Pacific and Asian women will assist with the earlier
detection of cancer to improve later outcomes.
Outcome sought: Increase in proportion of eligible
Māori, Pacific and Asian women who have had a
13 https://www.tepou.co.nz/initiatives/equally-well-physical-health/37 14 http://www.comcare.org.nz/wp-content/uploads/2017/01/Equally-Well-Physical-Health-Programmes.pdf
28
cervical cancer screening test in the previous three years.
Measure description: The quarterly number of eligible women screened in the previous three years divided by
the population of eligible women, by ethnicity.
Data Source: Data reported to the National Screening Unit quarterly.
ENHANCING SUICIDE PREVENTION
Rationale for selection: Suicide in Canterbury is a high cause of amenable mortality. Suicide within Canterbury
is inequitable with Māori accounting for 13% of 2010-2015 deaths. In Canterbury cross-sectorial groups are
coming together to work towards enhancing suicide prevention.
It is recognised that this measure is impacted by
some factors that are not amenable through actions
by the wider health system. By choosing to focus on
a change in the 10 year average rate this volatility is
expected to be reduced.
Outcome sought: Reduce the 10 year average suicide
rate in Canterbury, with a particular focus on
reducing the rate of Māori suicide.
Measure description: Suicide rate (provisional)
reported annually.
Data Source: Local data reported from Ministry of
Justice (provisional suicide) divided by Statistics NZ population data. Note: Provisional data includes suicides with
‘undetermined intent’ which after coronial review can be removed from final suicide data. Provisional data
includes South Canterbury DHB.
ACTIONS TO IMPROVE PERFORMANCE: AMENABLE MORTALITY
Contributory
Measure
Actions to Improve Performance Responsibility
Indicators of Healthy
Lifestyle
Refine Te Hā – Waitaha’s focus on priority populations
including:
o Maintaining enrolments and outcomes for our
Māori, Pacific and pregnant women at existing high
levels; and
o Collaboration around targeted intervention for
culturally and linguistically diverse (CALD)
communities through the employment of a
Mandarin speaking stop smoking practitioner and
increasing access to interpreting services.
Population Health and
Access Service Level
Alliance
Regular smokers in
Canterbury
Work with Smokefree Canterbury to further integrate
all local smoking cessation services including the PHO
delivered smoking cessation and Te Hā - Waitaha
services.
Population Health and
Access Service Level
Alliance
Improved Physical
Health for People
Experiencing Mental
Refine the current approach locally to achieve the
Equally Well outcomes of improved physical wellbeing
of people who experience mental health problems.
Mental Health
Workstream
29
Health and/or
Addiction Issues
Improved access to
cervical cancer
screening
Establish where there is a shortage of smear takers and
explore how to increase coverage to improve access for
priority group women (PGW).
Explore potential for employer funded cervical smear
tests for PGW and other ways to increase access to free
screening tests.
Collaborate with other services seeing PGW to promote
cervical cancer screening.
Population Health and
Access Service Level
Alliance
Enhancing suicide
prevention
Develop a cross-sectorial suicide prevention
governance committee and action plan.
Develop a Canterbury suicide prevention website.
Mental Health
Workstream
All Measures Advocate for a healthier environment through work
with providers and developers to increase opportunity
for both indoor and outdoor physical activity and access
to healthy food.
Population Health and
Access Service Level
Alliance
Emerging Measure Establish a process to influence Māori and Pacific 35-44
year olds in relation to cardiovascular disease risk later
in life.
PHO Education and
communications
30
System level measure:
YOUTH ACCESS TO HEALTH SERVICES
CANTERBURY’S EXPERIENCE
Our clinically-led priority focus on the ‘Access to Preventive Services’ domain for 2019/20 is to improve adolescent
access to dental services.
In 2017 19,012(63%) of the estimated 30,205
adolescents (School Year 9 to 17 years of age) in
Canterbury accessed DHB funded dental
services15. This utilisation rate is below the
national average and has changed little over the
previous ten years.
In 2018/19 Cantebrury has worked to
strengthen dental practices receipt of Year 9
referrals via the transfer for care process, and
work with the dental practices on their recall
processes. In addition, four schools with high
rates of Māori and Pacific children are being worked with to host focus groups with their students to enable
understanding of factors that impact adolescent engagement with services, and ways to increase access.
During 2019/20 we will use the information collected from the focus groups to develop and deliver an Oral Health
Service that is youth friendly and accessible.
While Canterbury’s Dental Service measure of youth access and utilisation focused on a specific part of preventive
health services, it will be used to generate lessons that could be applied more generally to young people’s perception of and willingness to use services.
MILESTONE
The Canterbury Health System’s agreed milestone is 63% of the adolescents from Year 9 to 17 years of age utilising the Canterbury DHB funded Dental Service at June 2020.
DELIVER AN ACCESSIBLE YOUTH FRIENDLY ORAL HEALTH SERVICE
CONTRIBUTORY MEASURES
Outcome sought: Increase adolescent utilisation of oral health services by developing a service for youth that is
accessible and feels welcoming.
Rationale for selection: Work completed during 2018/19 has led to the next tranche of work which is to review
youth oral health services by developing a service that is youth friendly. Utilisation data shows that while
adolescents are transferred to dental practices in Year 9, they are not using the services. Understanding what youth
15 Policy Priority 12 data
31
want in an adolescent oral health service will inform how to change the design of this service to encourage equitable
access.
Measure description: Adolescents utilisation of the Adolescent Oral Health Service by ethnicity.
Data Source: The Proclaim Payments System data linked to the Combined Dental Agreements.
ACTIONS TO IMPROVE PERFORMANCE: YOUTH ACCESS TO HEALTH SERVICES
Contributory Measure Actions to Improve Performance Responsibility
Deliver an accessible
youth friendly Oral
Health Service.
Assess the current service model of
Adolescent Oral Health Services.
Using information gained from the Focus
Group, work with youth to identify what they
want in an adolescent oral health service.
Oral Health Service
Development Group
System Level Measure Continue to explore other indicators that
could provide a more comprehensive picture
of youth access to preventative services.
Population Health and Access
Service Level Alliance.
32
System level measure:
BABIES LIVING IN SMOKEFREE HOMES
CANTERBURY’S EXPERIENCE
Our priority is to increase the number of babies
living in smokefree homes and to address the
ethnic variation between Māori, Pacific and
total population.
At June 2018 Canterbury’s percentage of Babies Living in Smokefree Homes at 6 weeks post-
natal of 61% compares favourably with the
national average for the Total population of
54%16. Viewed by ethnicity17 Canterbury’s results for the Māori population (49%) and
Pacific population (42%) are lower than
Canterbury’s Total population.
The number of pregnant women enrolling with smoking cessation services and remaining smokefree at the four
week follow-up is remaining fairly static. During 2019/20 we will be strengthening the pathway and incentive for
pregnant women to attend a smoking cessation consultation through linking this to our Sudden Unexpected Death
in Infancy (SUDI) safe sleep programme. All pregnant women who attend an initial consult with a stop smoking
practitioner will be offered a Pēpi Pod. It is expected that through promoting this service to Lead Maternity Carers
that more pregnant women who smoke will be linked with smoking cessation services.
During 2018/19 analysis undertaken on the birthweight of babies born in CDHB facilities between 2007 and 2016
found the mean birth weight of babies from mothers who smoked during pregnancy was lower than those with
mothers who did not smoke. Additionally, mothers who smoked were more likely to have preterm babies than
mothers who did not smoke. During 2019/20 we will use analysis of our birthing population to identify interventions
to reduce low birth weight and premature births among mothers who smoke.
MILESTONE
The November 2018 dataset provided to the DHB covering January to June 2018 was calculated using a revised
denominator. This has resulted in results vastly different to datasets available for previous years. The change in the
denominator used to calculate the percentage of babies living in smokefree homes means that we are unable to
accurately compare progress to previous six-month periods. We have therefore used this dataset as a standalone
to develop our 2019/20 milestone. The Ministry of Health advise that as data integrity improves they expect to see
an initial reduction in the rate of babies living in smokefree homes.
The ratio of Total Rate:Māori for babies living in smokefree homes is 1:0.81, and Total Rate:Pasifika it is 1:0.70. The
Canterbury Health System’s agreed milestone for June 2020 is to decrease the equity gap for Māori and Pacific to
16 The National Minimum Data Set for Babies Living in Smokefree Homes at November 2018. This dataset has been developed using a different denominator
than in the past. Due to this, datasets are not able to be compared to track progress towards our 2018/19 Milestone. 17 The National Minimum Data Set for Babies Living in Smokefree Homes at May 2018 by prioritised ethnic groups.
33
0.85 and 0.75 respectively, an increase in approximately 15 homes that are smokefree, and to continue to increase
the number of infants living in smokefree homes by 30 June 2020.
CONTRIBUTORY MEASURES
PREGNANT WOMEN ACCESSING SPECIALIST SMOKING CESSATION SUPPORT
Outcome sought: An increase in the number of pregnant women and their family/whānau who are smokefree. Rationale for selection: Engaging pregnant women and their family/whānau who are smokers in specialist smoking cessation support seeks to reduce infant exposure to harm from smoking through pregnancy, birth and in the
home environment. The number of women enrolling in Canterbury’s specialist smoking cessation service is an
indicator that an effective delivery pathway is in place, including:
The referring health professional has provided help
to quit, has knowledge of the specialist smoking
cessation service and how to refer; and
The provider of the specialist cessation responds in
a timely way to the referral. .
Measure description: The number of pregnant women
enrolling in Te Hā – Waitaha / Stop Smoking Canterbury,
by referrer type.
Data source: Reported quarterly from Te Hā – Waitaha.
OUTCOMES OF PREGNANT WOMEN ENGAGING IN SPECIALIST SMOKING CESSATION SUPPORT
Outcome sought: An increase in the number of pregnant women and their family/whānau who are smokefree. Rationale for selection: This builds on the previous measure as an indicator of whether women that engage in
Canterbury’s specialist smoking cessation service become smokefree.
Measure description: The smoking status of the pregnant
women enrolled in Te Hā – Waitaha.
Numerator: The proportion of pregnant women who, at
the 4-week follow–up, have not had a single puff in the
previous 2 weeks; this includes smoking status that is self-
reported or carbon monoxide (CO) validated.
Denominator: The number of pregnant women enrolled in
Te Hā – Waitaha.
Data source: Reported quarterly from Te Hā – Waitaha.
ACTIONS TO IMPROVE PERFORMANCE: BABIES IN SMOKEFREE HOMES
Measure Actions to Improve Performance Responsibility
Pregnant Women
accessing smoking
cessation
Strengthen the referral pathways from Lead Maternity
Carers to Te Hā – Waitaha by:
o Working with midwives and LMCs to
increase the number of clients motivated
towards smokefree care routinely;
Te Hā – Waitaha Steering
Group and the Pregnancy
sub-group of Te Hā –
Waitaha
34
o Develop a stop smoking clinic for pregnant
women who smoke, within a community
setting.
Pregnant Women
accessing smoking
cessation
Complete the evaluation of Canterbury’s Pregnancy Incentive Stop Smoking Programme and implement
any feasible quality improvement steps
recommended.
Te Hā – Waitaha Steering
Group and the Pregnancy
sub-group of Te Hā –
Waitaha
Detailed analysis of
infants in smokefree
homes data
Undertake a comprehensive analysis of patient level
data including by age and ethnicity, and from the
insights gained develop actions to increase the number
of babies in smokefree homes.
Child and Youth
Workstream
System Level Measure Use analysis of our birthing population to identify
interventions to reduce low birth weight and
premature births among mothers who smoke.
System Outcomes
Steering Group
35
APPENDIX ONE: OVERVIEW OF CANTERBURY’S SYSTEM LEVEL MEASURES RESPONSE
OVERVIEW OF SYSTEM LEVEL MEASURES RESPONSE = leading delivery on the measure = linked / contributing to delivery on the measure Updated March 2019.
Ch
ild
& Y
ou
th
Wo
rk S
tre
am
He
alt
h o
f O
lde
r
Pe
rso
ns
Wo
rkst
rea
m
Co
mm
un
ity
Se
rvic
es
SLA
Urg
en
t C
are
SLA
Ph
arm
acy
SLA
Po
pu
lati
on
He
alt
h
& A
cce
ss S
LA
Ma
na
Ak
e –
Str
on
ge
r fo
r
To
mo
rro
w
Cli
nic
al
Qu
ali
ty
Ed
uca
tio
n
Ora
l H
ea
lth
Ste
eri
ng
Gro
up
Imm
un
isa
tio
n S
LA
Re
ali
gn
/ D
HB
Se
rvic
e A
rea
s
Qu
ali
ty &
Sa
fety
Ex
pe
rt
Gro
up
Pro
ject
gro
up
PH
Os
/ D
HB
Pa
cifi
c R
efe
ren
ce
Gro
up
Māo
ri Re
fere
nce
Gro
up
Co
nsu
me
r C
ou
nci
l
Me
nta
l H
ea
lth
Wo
rk s
tre
am
Fa
lls
& F
ract
ure
s
SLA
Mid
wiv
es
Ru
ral
He
alt
h
Wo
rkst
rea
m
ASH rate 0-4
year olds
ASH rate ethnic
variation
Project
Oral Health 0-4
year olds
New Born
Enrolment
Accuracy of
Ethnicity
Capture
Acute Bed Days
Reduced Length
of Stay
Readmission
Rate
Polypharmacy
Expert
group
36
Ch
ild
& Y
ou
th W
ork
Str
ea
m
He
alt
h o
f O
lde
r
Pe
rso
ns
Wo
rkst
rea
m
Co
mm
un
ity
Se
rvic
es
SLA
Urg
en
t C
are
SLA
Ph
arm
acy
SLA
Po
pu
lati
on
He
alt
h
& A
cce
ss S
LA
Ma
na
Ak
e –
Str
on
ge
r fo
r
To
mo
rro
w
Cli
nic
al
Qu
ali
ty
Ed
uca
tio
n
Ora
l H
ea
lth
Ste
eri
ng
Gro
up
Imm
un
isa
tio
n S
LA
Re
ali
gn
/ D
HB
Se
rvic
e A
rea
s
Qu
ali
ty &
Sa
fety
Ex
pe
rt
Gro
up
Pro
ject
gro
up
PH
Os
/ D
HB
Pa
cifi
c R
efe
ren
ce
Gro
up
M
āori
Re
fere
nce
Gro
up
Co
nsu
me
r C
ou
nci
l
Me
nta
l H
ea
lth
Wo
rk s
tre
am
Fa
lls
& F
ract
ure
s
SLA
Mid
wiv
es
Ru
ral
He
alt
h
Wo
rkst
rea
m
Falls Prevention /
Reduction in Falls
Pasifika Futures
Engagement
Patient Experience
of Care
Expert
group
In-Hospital
Response Rate
In hospital
Engagement of
Family & Whanau
in Patient Care
Primary Care
implementation of
PES
Monitor / analyse
local response rate,
Identify common
focus area and
utilise feedback
37
Ch
ild
& Y
ou
th W
ork
Str
ea
m
He
alt
h o
f O
lde
r
Pe
rso
ns
Wo
rk
Gro
up
Co
mm
un
ity
Se
rvic
es
SLA
Urg
en
t C
are
SLA
Ph
arm
acy
SLA
Po
pu
lati
on
He
alt
h
& A
cce
ss
SLA
Ma
na
Ak
e –
Str
on
ge
r fo
r
To
mo
rro
w
Cli
nic
al
Qu
ali
ty
Ed
uca
tio
n
Ora
l H
ea
lth
Ste
eri
ng
Gro
up
Imm
un
isa
tio
n S
LA
Re
ali
gn
/ D
HB
Se
rvic
e A
rea
s
Qu
ali
ty &
Sa
fety
Ex
pe
rt
Gro
up
Pro
ject
gro
up
PH
Os
/ D
HB
Pa
cifi
c R
efe
ren
ce
Gro
up
Māo
ri R
efe
ren
ce
Gro
up
Co
nsu
me
r C
ou
nci
l
Me
nta
l H
ea
lth
Wo
rkst
rea
m
Fa
lls
& F
ract
ure
s
SLA
Mid
wiv
es
Ru
ral
He
alt
h
Wo
rkst
rea
m
Amenable
Mortality
Green
Prescription
Referrals
Enrolment in Te
Hā - Waitaha
Te Hā Waitaha
Steering
Group
Enrolments in
Smoking
Cessation
provided by PHOs
Cervical Cancer
Screening
Enhancing
Suicide
Prevention
Youth Access to
Health Services
Deliver an
accessible youth
friendly Oral
Health Service.
38
Ch
ild
& Y
ou
th
Wo
rk S
tre
am
He
alt
h o
f O
lde
r
Pe
rso
ns
Wo
rk
Gro
up
Co
mm
un
ity
Se
rvic
es
SLA
Urg
en
t C
are
SLA
Ph
arm
acy
SLA
Po
pu
lati
on
He
alt
h
& A
cce
ss S
LA
Ma
na
Ak
e –
Str
on
ge
r fo
r
To
mo
rro
w
Cli
nic
al
Qu
ali
ty
Ed
uca
tio
n
Ora
l H
ea
lth
Ste
eri
ng
Gro
up
Imm
un
isa
tio
n S
LA
Re
ali
gn
/ D
HB
Se
rvic
e A
rea
s
Qu
ali
ty &
Sa
fety
Ex
pe
rt
Gro
up
Pro
ject
gro
up
PH
Os
/ D
HB
Pa
cifi
c R
efe
ren
ce
Gro
up
Māo
ri R
efe
ren
ce
Gro
up
Co
nsu
me
r C
ou
nci
l
Me
nta
l H
ea
lth
Wo
rkst
rea
m
Fa
lls
& F
ract
ure
s
SLA
Mid
wiv
es
Ru
ral
He
alt
h
Wo
rkst
rea
m
Smokefree
Infants
Te Hā Waitaha
Steering
Group
Pregnant Women
accessing
smoking
cessation
Ma
tern
ity
Se
rvic
es
Outcomes of
pregnant Women
accessing
cessation
Detailed analysis
of infants in
smokefree
homes data
